Episode 22: The Truth About Endometriosis, Through the Eyes of a Functional Gynecologist

Hi, I'm Dr. Tabitha, the functional gynecologist. I'm a board certified, OB, GYN and functional medicine physician. I've embraced the world of functional medicine and wellness through my own personal health journey. And I'm super excited to share my wisdom and unique perspective as it pertains to women's health. So if you're struggling with hormone imbalance, weight gain, period issues, anxiety, insomnia, you name it, then you've come to the right place. I want to be your functional gynecologist. So welcome. Hi friends. Today's topic is on endometriosis. So normally we have endometrial cells that line the inside of our uterus, and that's what grows every month from estrogen signals. Once you ovulate, progesterone tells those endometrial cells to stay put because you might have fertilization and implantation of an embryo into that lining. Once you ovulate, progesterone tells those endometrial cells to stay put and keep growing because you might have fertilization and implantation of an embryo into that lining. But if you don't get pregnant, your estrogen and progesterone levels drop and the lining gets the signal to release and shed. You make prostaglandins that cause cramping, and then you bleed. The same thing happens with endometriosis just outside of the uterus. So what is endometriosis? Endometriosis happens when the microscopic endometrial cells inside the uterus start start growing on the outside. They usually backflow through the fallopian tubes and attach themselves to areas in your pelvis. The ovaries are the most common site, and it can happen on the outside of the ovary, but often the ovaries grow cysts filled with a sticky brown substance that actually looks like Hershey's syrup when you open them. And those are called endometriomas, the anterior and posterior cul de sac, which are the spaces in front where the bladder lives and behind the uterus where the rectum lives. That's the second most common places for endometriosis to grow. That's why women often have feelings of recurrent bladder infections when they don't actually have an infection or they get pain and diarrhea before and with their periods. The ligaments that hold up the uterus are the next most common place, and that's often why intercourse hurts. The endometriosis causes those ligaments to become scarred and shortened so your uterus can't move the Way it's supposed to with sex, it is painful. And then the outside of the uterus, the fallopian tubes, your bowels and your appendix, those are the other common areas for it to grow on. So not only does it sometimes backflow through the fallopian tubes during a period, but endometrial cells can also get into your pelvic cavity during surgeries, especially C sections, where your uterus is actually cut open and the endometrial cells are spilled into the pelvis. Sometimes women get it growing in their C section, scar on their skin, actually. So, as a surgeon, I was always careful to irrigate and clean out all the blood and tissue away when closing up a patient during a C section, because I did not want that to happen. So, ladies, having a surgeon who brags about how fast they can finish a C section is not someone you want operating on you. That's a whole other discussion. But let me just say you want a surgeon who closes every layer that they opened up and irrigates your cavity well, because I always say the solution to pollution is dilution, which means you want to irrigate well, prevent endometrial cells, inflammatory cells, cystic fluid, blood, and bacteria from setting up residents where it doesn't belong. This decreases your risk of infection, scar formation, further endometriosis, and is associated with less pain post operatively. Remember, those individual cells are microscopic, so we can't see them until they congregate enough of themselves to create a piece of tissue. Okay, sorry about that tangent, but it's important information, something worth discussing with your prospective surgeon. So some women are born with endometrial cells outside of their uterine cavity because during our development as an embryo, those cells have to migrate from our abdomen down into our pelvis. But we think that's a really small percentage of women. Actually, you can have all, all of these possibilities as a reason why you have endometriosis. Some theorize that every woman has endometrial cells outside of her uterine cavity and has the potential to develop endometriosis. Outside of being a research subject, it's not really possible to know for sure how you got it. So the lesions that grow can be superficial and usually grow in response to your hormones, just like inside your uterus, and then they bleed, which causes pain and irritation to the organ that it's growing on. Or it can grow deep and be infiltrating and cause scarring and cause the tissue to be deformed. Like I said with your ligaments, how they get shortened and they can no longer move and do what they're supposed to do. So just as important as the cells being where they're not supposed to be is why are they growing? So as an obgyn resident back in the day, I was taught that endometrial lesions, or implants as they're often referred to, are endometrial cells that turn into fibrous tissue, blood or cysts. The breakdown of the red blood cells by inflammatory cells results in the formation of pigmented histiocytes and hemosiderin laden macrophages. That was always the test question on exams. So the older the lesion, the more likely it is to be pigmented. So if you listened to episode number 17, understanding your immune system, then you remember me explaining what a macrophage is. It's a white blood cell from your immune system that's trying to get rid of what doesn't belong to protect you. If you haven't listened to that episode, you definitely should. It will help you understand endometriosis even more. So normally when you have aberrant cells in the body that don't belong there, like endometrial cells in your pelvic cavity, your body sends out scavengers from your immune system to go eat them up and get rid of them. But if you have chronic inflammation in your body, then your immune system oftentimes doesn't send the right signals or cells to do its job correctly and can actually make the problem worse. This is partly how cancer develops. We constantly have cells that are getting old or full of toxins or viruses, or their DNA is being damaged. Normally our body would have those cells go into apoptosis and kill themselves off, or immune cells like macrophages would come and eat them. But somet to multiply and spread their harmful contents because there's nothing there keeping them in check and getting rid of them. An easy example to understand is a skin cell that keeps getting exposed to the harmful UV rays in a tanning bed. So if the cell doesn't have time to repair because of repeated exposure, or if your immune system isn't functioning well, then that cell will multiply and its damaged DNA will eventually create a cancer cell which multiplies. So a Meta analysis of eight studies done by the University of Oxford in 2014 identified at least six gene mutations that were statistically associated with endometriosis. In addition, a study that analyzed DNA sequencing of non malignant deep endometriosis lesions. So it's not cancer, it's benign. Reported mutations in 79% of lesions and mutations in the known cancer driver genes, ARAD1A, Pike3CA, CRAS and PPP2R1A in 26% of lesions. So you don't need to know what all these genes are. I just want you to know that the prevalence of cancer driver mutations in non malignant cells is partly why we can get such aggressive, deep infiltrating, scarring lesions. Have you ever heard of CA125? So that is a common serum cancer antigen that's elevated in ovarian cancer. So oftentimes we will draw CA125 level in the blood when we're concerned about a postmenopausal woman having an ovarian cyst and whether we're trying to decide if it's cancerous or not. So this serum antigen is actually elevated in women with endometriosis. So there is a link to endometriosis and ovarian cancer and a lot more research needs to be done. Unfortunately, we can't use it to diagnose because so many other processes cause that to increase. But it's a great example of how this disease is driven by cellular dysfunction, disease, disruption of our normal DNA sequencing, and the incorrect response from our immune system. So I'm not saying that you're going to get ovarian cancer if you have endometriosis, but what I'm saying is that this is all happening at a cellular level that needs to be corrected. So nothing is an overnight process. Every process in your body can be intervened upon. We want to stop those endometrial cells from growing and we want to remove them from where they don't. We do this by supporting our immune system to be able to function properly and avoid things that cause dysfunction and DNA damage. I'll talk about that more in a bit. First, let's talk about who is more likely to develop endometriosis and who's not. So about 10% of reproductive age women globally have endometriosis. Age 25 to 35 is where we see the peak prevalence. It's difficult to determine the prevalence of endometriosis in the general population because some women are asymptomatic and those with symptoms can have varied or nonspecific presentations. The most common symptoms are pelvic pain that starts a week before the period starts, pain with intercourse, heavy painful periods, diarrhea with your period, bladder irritation and infertility. Additional symptoms include low back pain, nausea, vomiting, lack of energy. All these symptoms are less common. Symptoms can occur alone or in combination. An increased number of symptoms is usually associated with an increased likelihood of endometriosis. But here's the deal, ladies. The only way to know for sure if you have endometriosis is to have surgery. Because of this, Most women go 10 to 12 years having symptoms before they receive a proper diagnosis. This is heartbreaking to me. I often see women in my office five to 10 years after they have struggled with pain and heavy periods. And their primary physician has run the gamut of birth control pills, pain medications to manage their symptoms. Unfortunately, I've even seen women be put on narcotics and opioids like Vicodin, Norco, oxycontin for this type of pain, which it's not indicated for and it really does not help. So my heart goes out to those women who have not been properly diagnosed and who have not been treated appropriately. So anyway, as a surgeon, for me to diagnose your endometriosis, I would need to do a laparoscope that is taking you to the or putting you to sleep and putting a camera through the belly button to see the endometriosis in your pelvic cavity. During laparoscopy, areas of peritoneal endometriosis can appear as red raised flame like patches, whitish opacifications, yellow brown discolorations, translucent blebs, or reddish blue irregularly shaped islands of implants. This is also another reason why it has been so difficult to get a correct diagnosis. The appearance of some blue brown lesions has also been described as powder burns. And the peritoneal surface can actually be scarred and puckered down and created defects that look like holes called Allen Masters defects. You can even get nodules and cysts. Rarely, endometriosis may mimic the appearance of a malignant or cancerous tumor. More commonly, it causes dense fibrous adhesions where organs are scarred together and that signifies severe disease. So I can go into a pelvis and see the bowel scarred to the ovary and the uterus and the fallopian tubes. I've had many cases where the fallopian tube isn't even identifiable, or I've had to dig the ovary and fallopian tube out of a terrible scarred up bowel mess. It can be quite severe. An ultrasound will show an endometrioma cyst on your ovary, but usually you can't see the lesions or the implants or the scarring because it's not large enough to be identified on ultrasound. So just because an ultrasound doesn't show anything necessarily doesn't mean you don't have endometriosis. So if you are having symptoms, you need to be diligent and continue to look for answers. Oftentimes, women are diagnosed empirically, meaning their doctor assumes they have endo based on their symptoms and exam and then treats them without doing surgery to confirm that diagnosis. And there's many reasons for doing that. Surgery is invasive. You know, you have general anesthesia, There's a high cost to it, there's risks involved. But then we don't know the severity of your disease or the exact location or even if you have endometriosis at all. It could be an incorrect diagnosis. So word of warning. Traditionally, we diagnosed empirically because we didn't have good surgical equipment and techniques to do anything about those lesions, even if we saw them when they were there. So looking inside, we would say, yep, you have that diagnosis, but then your treatment would be the same. We would close you up and put you on birth control pills. So skipping the surgery made sense. Fortunately, with the advancement of laparoscopic tools and the advent of robotic surgery, we can do endometrial resection surgery, which is quite successful at treating active endometriosis lesions. But here's the caveat. It will grow back if you aren't dealing with the root cause issue. And that's where functional medicine comes in. Okay, so endometriosis is more often seen in women who are nulliparous, meaning you've never been pregnant, who had early menarche before age 11 or late menopause, have had menstrual cycles more often than every 27 days, have heavy menstrual bleeding or an obstruction of their flow from a congenital anomaly, exposure to destination in utero, which you would probably know, a Height greater than 68 inches, lower BMI, exposure to severe physical and or sexual abuse in childhood or adolescence, and a high consumption of transunsaturated fats, AKA the standard American diet of processed foods in boxes and bags. So that's a lot of important information. It sounds like endometriosis is more often seen in women with high levels of unbalanced estrogen, exposure to xenoestrogens or pharmaceuticals, women who have emotional and mental trauma that they have not processed and dealt with, and the standard American diet, those unhealthy fats that damage our DNA and cells. I'm going to talk about that more in a little bit. So factors associated with a decreased risk of endometriosis include having multiple babies, extending your times of nursing or breastfeeding and late menarche after the age of 14. These are times when you're not producing and cycling your hormones. That is why conventional medicine has aimed at shutting down your cycle as a means of treating endometriosis. The problem is women don't feel well when they aren't cycling. And it's not healthy for the other systems in our body, like our heart, brain and bones, to have that cycle constantly suppressed. One other very important factor that's been associated with decreased risk of endometriosis was found in a study done at Brigham and Women's Hospital and Harvard Medical School in 2010. They showed that increased consumption of long chain omega 3 fatty acids was associated with a reduced risk of endometriosis. So women, eat your avocados, your olives, olive oil, nuts, seeds and fatty fishes. Race may also be a risk factor because the prevalence of endometriosis has been reported as being higher in white and Asian women compared with black and Hispanic women. So, moving on, once endometriosis is established, the the process appears to cause symptoms through inflammatory changes. Endometriosis related pelvic pain is associated with the production of inflammatory and pain mediators as well as neurologic dysfunction related to the lesions. Women with endometriosis related pain have an increase in nerve fibers at the site of their lesions which signals more pain. Estrogen acts as a neuromodulator that magnifies the sensory innervation of pain. Inflammatory cells stimul stimulate the nerves to become more sensitive and the chronic pain induces changes in the central nervous system, AKA your brain to cause greater recognition of that recurrent pain. Infertility and subfertility happen from anatomic distortion of the tissue, from scarring and adhesions and endometriomas. This all happens because of the production of inflammatory substances like prostaglandins, cytokine and growth factors that are hostile to normal tissue and cause inflammation. Then fibrous changes and eventually scarring and adhesions. So why does your body make these inflammatory chemicals? It's usually because of inflammation happening in other parts of your body, namely the gut. So the SAD diet or standard American diet is food that is full of pesticides, synthetic hormones, plastics, antibiotics and halides that destroy the lining of our gut and cause increased intestinal permeability. This lets chemicals, proteins and other toxins into our bloodstream which cause our immune system to respond. It's trying to protect us by attacking those things. But when our immune system has to constantly attack and respond, it sometimes over responds and attacks our own healthy tissues. Creating an autoimmune disease. Or it's so busy attacking those things that it can't properly attack other things like or endometrial cells. It also changes our gut microbiome, the bacteria who live in our gut and essentially run the show. The standard American diet is associated with more gram negative bacteria and they produce a toxin called LPS or lipopolysaccharide. This causes systemic inflammation. LPS is more often seen in women with endometriosis. So this systemic chronic inflammation, increased oxidative stress is not only seen in endometriosis, but it's also seen in conditions like atherosclerosis and heart disease. Studies published out of Brazil and Rome have shown an association with increased atherosclerosis in women who have endometriosis. So Brigham and Women's Hospital and Harvard Medical School did a study with over 116,000 women and it showed that women without heart disease or stroke with laparoscopically confirmed endometriosis had an increased risk of going on to have a myocardial infarction, which is a heart attack, coronary artery bypass graft surgery, or angioplasty stent placement compared with women without endometriosis. The risk of combined coronary heart disease was also higher in women who underwent hysterectomy or OO oophorectomy compared with those who did not. So conventional treatment is not the best answer for your overall health, ladies. Treating the systemic inflammation that root cause is the best treatment and it's much safer. Conventional treatment usually consists of suppressing your menstrual cycle, in other words, your hormone production by putting you on a continuous birth control pill or a progestin only shot called Depo provera. For some women, this suppresses the growth enough to help the pain and bleeding, but often comes with awful side effects of weight gain, headaches, thinning of the bones and depression. And if those don't work well enough to suppress the growth, Lupron is often tried, which actually puts you in a menopausal state of very low estrogen and progesterone. I'm telling you, every patient I've ever put on those felt terrible. Most women say the improvement in pain is not worth the side effects. That isn't even considering the long term effects that menopausal levels of hormones has on the rest of your body. As a reproductive age woman, you do not want menopausal levels of hormones in your body that will age you much faster. It will age your bones, your skin, your eyes, Your heart, your brain, and the list goes on. So as a functional gynecologist, I would argue that it's imperative to tackle the root cause of this disease, your systemic inflammation. This is done by completely abandoning the standard American diet, that SAD diet. You need to embrace a clean, organic, plant based diet. So for detailed information about what you should and shouldn't be eating, please listen back to episode four, Food as Medicine. In that episode I explained how dairy, sugar, gluten and sometimes eggs can increase inflammatory cytokines. I would definitely recommend avoiding those foods if you're suffering from endometriosis. Bromelain is found in pineapple and it helps heal your intestinal lining. So that would be something that you would want to start taking or eating more of. Berberine is a supplement found in Chinese herbs that repairs intestinal permeability and neutralizes that lps, that horrible lipopolysaccharide toxin produced by those gram negative bacteria. So definitely get berberine, NAC or N. Acetylcysteine is a natural anti inflammatory supplement that replenishes glutathione levels. Glutathione is a major antioxidant that your body needs to go clean up all those damaged cell, all those free radicals to help your body heal. Zinc is an important mineral for hormone conversion and it's often deficient in patients with endometriosis. So make sure you're getting enough zinc by eating legumes, nuts, seeds, shellfish and then supplement if you need to. Curcumin is the active compound found in turmeric. It's a root used in many Indian dishes, gives it that bright color, orange color. So curcumin decreases inflammatory proteins and it's safe for long term use. So I would definitely add that to your regimen. It's widely used for other inflammatory pain conditions like arthritis as well. So for more information, please listen to episode four. Getting endometriosis into remission naturally also requires that you actively manage your stress to decrease your cortisol and glucose production. So if you haven't listened to episode three hormone imbalance, I urge you to go back and listen because I explain in detail how chronic stress causes systemic inflammation and disease. Getting on board with managing your stress and getting it under control will help you get your endometriosis under control. I guarantee that you can get your endometriosis under control by healing your gut and supporting a healthy, functioning immune system that isn't constantly overreacting and trying to put out fires. I do this with my patients all the time in my office and you can do it too. So if you're currently flared up, I recommend you implement these recommendations asap. If your symptoms aren't significantly improved within three to four months, I recommend you find a good GYN surgeon to remove your active growth and adhesions as best she can and then focus on keeping that inflammation at bay so that it doesn't grow back after your surgery. Sometimes it's bad enough that we need to go in and remove what's already there and then focus on preventing new growth. The same goes if you're on OCPs, birth control pills, depo or Lupron injections. Start by overhauling your diet, decreasing your stress with daily exercise, meditation, counseling, yoga, whatever it takes. Don't smoke and keep alcohol to a minimum. You should also start taking a pharmaceutical grade multivitamin and the supplements that you need to give your body the necessary vitamins and minerals it needs to perform its cellular functions to heal and be able to get off those harmful medications. I promise it's completely doable. And remember this, our bodies were designed to maintain homeostasis and heal themselves. Endometriosis is a condition that develops when our body isn't functioning appropriately. We just need to remove the bad stuff that is getting in the way from our body. Being able to do that, once we remove those impedances and support a healthy immune system and rebalance our hormones to the way they should be, we can put that disease into remission. I hope this information helped you understand endometriosis a little better. I hope you're feeling encouraged and empowered knowing that you have some control over what's going on in your own body. You're not at the mercy of your doctors. You can take major action to treat your own condition and help yourself feel better. Please follow me on Facebook and Instagram @Doctor Tabitha D R T A B A T H A that's three A's, no eyes. Send me your questions or comments about this. I want to help you heal. This is the only reason I do this podcast. I don't get paid, it's quite time consuming, but if I'm helping at least one woman heal naturally then it's worth it. If you're enjoying this and finding it helpful, I would ask that you hit the subscribe button and give me a review. Five stars would be amazing. That way I can keep bringing you this information. Now go do something loving for yourself. Take back your health, find your voice and know you have a choice. It's your body, so treat it like the castle that it is. And it will house you and protect you for as long as you maintain it. Till next week. Peace, my friends.